MEDICARE: DR. MONTAGUE CHARLES GONZALES DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6677	OR

General Provider Information

NPI Number	:	1811978802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MONTAGUE CHARLES GONZALES DMD

Provider Business Mailing Address
First Line	:	18612 WILLAMETTE DR
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-1708
Country	:	US
Telephone Number	:	503-635-4411
Fax Number	:	503-635-4117

Provider Business Practice Location Address
First Line	:	18612 WILLAMETTE DR
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-1708
Country	:	US
Telephone Number	:	503-635-4411
Fax Number	:	503-635-4117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/08/2007

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